Transplants are Never Simple: Collaboration Key to Beating Odds
Michael Moore was balanced precariously between a rock and a hard place, although in his case it was his heart and his liver. Fixing only one couldn't be done without putting both – and Moore – in high peril. Such competing interests are classic medical Catch-22s. Often, those situations have unhappy endings.
Yet, three years later, Moore's eyes twinkle with fun, his step is strong and lively and he's learning to play the guitar, something he's always wanted to do. What saved Moore was a highly unusual, two-fer collaborative surgery performed by Stanford Hospital & Clinics liver transplant team, one of the best in the nation, and Stanford's cardiothoracic team, also one of the best.
"We don't take no for an answer," said Moore's physician, Stanford transplant hepatologist Tami Daugherty. "We have the physicians to be able to support high-risk patients. We have the drive to provide excellent care for everyone, even for people who can't get that care at other places. At Stanford, there's no 'I can't do it.'"
Moore's journey toward Stanford and his surgery in 2007 began more than a decade ago, when he woke up one morning so swollen and bloated he knew something was very wrong. Invaded by a virus, his liver had started to lose its ability to manufacture proteins, to metabolize and store fats and carbohydrates and to rid the body of harmful toxins. Moore could still work, but he tired far more quickly. Another health emergency sent him to a local hospital where doctors told him he would need a liver transplant.
People who need a healthy organ of any kind face long waiting lists. This fall, more than 16,000 people in the U.S. were on the waiting list for a liver. Some may wait as long as two years.
Not just the liver
Moore's Stanford hepatologist put him on medications that put him into a biological remission. That gave him hope that he could stay alive long enough to move up the line for a transplant. That was before the change in organ transplant lists that adjusted for medical need, putting the sickest patients first. Moore's care at Stanford included all of his body. Moore's heart was checked out by an electrocardiologist, who found something that Moore had no idea was anything dangerous. "She goes, 'What's that?' I said, 'It's this buzzing I've had all my life.' It turned out I had a hole in my aortic valve that had enlarged and weakened my heart."
Physicians used a technique called ablation, an adjustment made with electricity, to stabilize, at least temporarily, the behavior of Moore's heart. "When they did my heart," Moore said, "they said it was lucky I got in because my heart probably wouldn't have lasted a week."
We take care of the whole patient, not just the liver. Life is not static and everything affects everything else.
The comprehensive viewpoint that sent Moore for a heart evaluation is part of what supports the Stanford liver transplant program's success rate. Since 1991, the liver transplant team has performed more than 800 adult liver transplantations, consistently exceeding national patient survival rates at the one- and three-year marks after transplantation. The team includes five transplant surgeons, six transplant hepatologists, two transplant psychiatrists and a support staff that includes social workers, dieticians, nurses, nurse practitioners, physician assistants, pharmacists, educators, and patient and financial coordinators who specialize in transplant patient care. "We take care of the whole patient," said Daugherty, "not just the liver. Life is not static and everything affects everything else."
Once Moore's heart problem was identified, it represented a major complication. With a failing heart, Moore couldn't get a liver transplant. And his liver condition meant the heart repair would be too dangerous. "It was a Catch-22," Daugherty said. The liver team consulted with the heart team to figure out how to replace Moore's aortic valve and transplant a liver at the same time, something very rarely done. The heart condition also helped Moore get his new liver. Under a new organ listing procedure revised to give transplant priority based on medical need, Moore's name was bumped to the front of the line. As soon as a liver became available, the Stanford heart and liver teams would work together in one back-to-back procedure.
"The great thing about transplant is that we all work together well," said Daugherty. "That's what I really enjoy about it."
Understanding Your Liver
The liver is the largest solid organ in the body. It filters toxins from the blood, processes fats, makes proteins, stores some vitamins and minerals, and metabolizes medications. When it fails, many body systems also falter.
Taking Care of Your Liver
• Avoid toxic substances, including industrial chemicals, and excessive alcohol consumption
• Maintain a healthy weight. Don't eat a high proportion of fatty foods.
• Get vaccinated against Hepatitis A and B.
Common Causes of Liver Failure
• Cirrhosis, which transforms normal liver tissue into scar tissue.
• Hepatitis A, B, and C vary greatly in behavior, but all can damage the liver.
• Autoimmune system disorders
When to See Your Doctor
• Skin develops a yellow tinge
• Unexplained fatigue
• Swelling of legs
• Easy bruising
• Not everyone who develops a liver disease needs a transplant. Many people are able to manage their disease for years as a chronic illness. When that is no longer possible, then transplant is considered. First, a prospective patient will go through an extensive evaluation to qualify to be on the waiting list. The United Network of Organ Sharing, under a federal contract, maintains that list. The list is ordered by medical need.
For more information, visit stanfordhospital.org/livertransplant or call 650-498-7878.
Stanford's liver transplant programs – in fact, all its transplant programs – include a thorough evaluation process to make sure a patient will be able to cope with life after transplant and has a good support system to help. Once a patient is accepted and even after surgery, the program encourages his or her participation in one of the special support groups Stanford provides its patients. Having others to talk to about the experience is a crucial part of transplant success. The hospital also sponsors a support group, not commonly available, for the transplant patient caregivers who are such an important part of pre- and post-transplant life.
"No one can really understand what it's like to have a liver transplant until they have one," Daugherty said. "It may seem to be a no-brainer, but it's not." At one of his support group meetings, Moore met the first person to have the kind of double surgery he was being offered, "and he was feeling fine and back to work. I was never in fear for my life."
Not only did I have a fleet of the best doctors, but the next generation was there, also learning from the best.
The surgery took 17 hours and Moore began his recovery, cheered on by a somewhat larger team of professionals. "One day, my heart team came in and my liver team came in, all at one time," said Moore, "and they were high-fiving each other like a bunch of high school kids who had just won the homecoming game!"
The serendipity of Moore's medical care had already made itself clear months before. When he was working at a local restaurant, three doctors were regular customers. "I knew they were on call and didn't have much time, so as soon as I saw them in the parking lot, I'd order their dinners and get them set up. We'd talk baseball and bicycling and sports. I never really introduced myself and I never knew their names."
When Moore returned to work after months off for medical care before his transplant, one of those regular doctor customers asked where he'd been. "I tell him the story of my liver and he goes, ‘Mike, do you know what I do? I'm the head of liver transplant at Stanford. He ended up overlooking my operation, and was cracking jokes with his colleagues that he was drumming up business at local restaurants!" The man Moore had been serving for so long was Carlos Esquivel, MD, PhD. Esquivel is surgical director of the Liver Transplant program and chief of the hospital's Division of Transplantation.
Moving forward and giving back
Moore takes pride in having been a part of Stanford's function as a training center for physicians. "Not only did I have a fleet of the best doctors," he said, "but the next generation was there, also learning from the best." Stanford's transplant team is also actively involved in research, in particular to find ways to reduce post-transplant medication needs and to broaden transplant possibilities.
For all transplant patients, life after their life-giving surgery requires many changes. The immunosuppressant drugs that Moore and other transplant patients take to prevent rejection of their transplant can raise the risk of post-transplant diabetes. Moore did develop diabetes. He is doing everything he can to be as healthy as he can. He eats a low-fat diet of mostly fruits and vegetables. He has become even more physically active than before he became so ill: He cycles, walks and lifts weights. He loves being outdoors as a volunteer marshall and starter at the Stanford Golf Course.
I've just been getting better every day. I never thought I would actually get to the point where I feel the way I do.
He is also doing as much as he can to give back to the hospital. He volunteers hours each week working the phone for Farewell to Falls, a program that offers home evaluations of safety risks in the homes of seniors. Moore's warm and concerned tone makes him very popular with the program's clients. He also works with the American Liver Foundation, the Alzheimer's Association and the American Cancer Foundation.
His volunteer work has been "the most rewarding thing I've ever done. I'll do it until the day I drop. Except for my diabetes, I'm feeling better than I have in 20 years," said Moore, 59. "I'm working to get control of my diabetes, the last battle in my health. But I've been making great steps. I've just been getting better every day. I never thought I would actually get to the point where I feel the way I do."